Hyperglycemia and outcomes from pediatric traumatic brain injury

BACKGROUND: The clinical significance of hyperglycemia after pediatric traumatic brain injury is controversial. This study addresses the relationship between hyperglycemia and outcomes after traumatic brain injury in pediatric patients. METHODS: We identified trauma patients admitted during a single year to our regional pediatric referral center with head regional Abbreviated Injury Scale scores > or = 3. We studied identified patients for admission characteristics potentially influencing their outcomes. The primary outcome measure was Glasgow Outcome Scale score. RESULTS: Patients who died had significantly higher admission serum glucose values than those patients who survived (267 mg/dL vs. 135 mg/dL; p = 0.000). Admission serum glucose > or = 300 mg/dL was uniformly associated with death. Admission Glasgow Coma Scale score (odds ratio, 0.560; 95% confidence interval, 0.358-0.877) and serum glucose (odds ratio, 1.013; 95% confidence interval, 1.003-1.023) are independent predictors of mortality in children with traumatic head injuries. CONCLUSION Hyperglycemia and poor neurologic outcome in head-injured children are associated. The pathophysiology of hyperglycemia in neurologic injury after head trauma remains unclear.     

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.     

Cerebrospinal fluid biomarkers versus glasgow coma scale and glasgow outcome scale in pediatric traumatic brain injury: the role of young age and inflicted injury

The Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) are widely used clinical scoring systems to measure the severity of neurologic injury after traumatic brain injury (TBI), but have recognized limitations in infants and small children. Cerebrospinal fluid (CSF) concentrations of neuron-specific enolase (NSE) and S100B show promise as markers of brain injury. We hypothesized that the initial GCS and 6-month GOS scores would be inversely associated with CSF NSE and/or S100B concentrations after severe pediatric TBI. Using banked CSF obtained during ongoing studies of pediatric TBI, NSE and S100B were determined in CSF collected within 24 h of trauma from 88 infants and children with severe TBI (GCS < or = 8) versus 20 non-injured controls. Victims of inflicted (iTBI) and non-inflicted TBI (nTBI) showed similar (>10-fold) increases in both NSE and S100B versus control. Both markers showed overall significant, inverse correlation with GCS and GOS scores. In subgroup analysis, both markers correlated significantly with GCS and GOS scores only in older (>4 years) victims of nTBI; no correlation was found for patients < or =4 years old or victims of iTBI. While confirming the overall correlations between GCS/GOS score and CSF NSE and S100B seen in prior studies, we conclude that these clinical and CSF biomarkers of brain injury do not correlate in children < or =4 years of age and/or victims of iTBI. Although further, prospective study is warranted, these findings suggest important limitations in our current ability to assess injury severity in this important population.     

颅脑损伤患者早期D-二聚体含量与伤情及预后的关系

目的探讨血浆D-二聚体(D-dimer,DD)含量作为早期观察因子在颅脑损伤患者伤情评估、预后预测中的作用。方法通过对刚入院63例单纯颅脑损伤患者血浆D-二聚体含量的测定,探讨D-二聚体含量与格拉斯哥昏迷分析(GCS)、脑CT扫描中线移位程度及格拉斯哥预后评分(GOS)的关系。结果颅脑损伤早期就出现D-二聚体含量增高;D-二聚体含量与GCS呈负相关,与中线移位程度呈正相关,D-二聚体含量越高伤情越重;D-二聚体含量与GOS呈负相关,D-二聚体含量越高预后越差。结论伤后早期D-二聚体含量测定有助于颅脑损伤患者伤情评估及预后预测。     

Severity of cervical spine ligamentous injury correlates with mechanism of injury,not with severity of blunt head trauma

Clearance of the cervical spine (CS) in obtunded trauma patients in an intensive care unit is problematic. Patients with no osseous injuries have potential unstable extradural supportive soft tissue injury. Evaluation of the supporting structures involves dynamic fluoroscopy or MRI both of which have inherent risks and convenience issues. Defining which of these patients are at highest risk for severe supportive structure injury may improve resource utilization for CS clearance. The purpose of this study was to evaluate clinical factors that may predict the probability of CS supportive soft tissue injury in patients with traumatic brain injury. Patients who sustained traumatic brain injury with intracranial pathology, absence of CS osseous injury, and a limited cervical spine MRI within 72 hours of injury were included. Potential clinical predictors included the severity of the traumatic brain injury defined by the Abbreviated Injury Severity Score for the cerebrum and initial Glasgow Coma Scale, the Injury Severity Score (ISS), mechanism of injury, and high versus low-velocity mechanism. Severity of soft tissue/ligament injury was graded by MRI findings. One hundred twenty-five patients met the study criteria; 81 had negative MRI findings and in 44 the MRI study was positive for potentially unstable injuries. High-velocity mechanisms of injury and ISS--not the severity of the traumatic brain injury or initial Glasgow Coma Scale score--were statistically significant predictors of severe CS supportive soft tissue injuries. Obtunded blunt trauma patients who have been involved in high-velocity-mechanism incidents and have high ISS are at greatest risk for extradural supportive soft tissue CS injuries. These patients should either remain in CS immobilization until clinical evaluation can be completed or undergo further evaluation of their supportive soft tissue structures by MRI or fluoroscopic flexion/extension.     

Early metabolic and neurologic predictors of long-term quality of life after closed head injury

Research has begun to identify early markers that predict survival after traumatic brain injury. In this study, trauma and biochemical indicators of severity were used to predict quality of life in 61 adults with traumatic brain injury and no damage to other organ systems. Severity markers available within 24 hours of injury were predictive of later psychosocial, behavioural and social role functioning. Multiple regression analyses demonstrated that the Glasgow Coma Scale, plasma glucose levels, leukocyte cell count and serum potassium concentration accounted for 12% to 66% of variance in certain measures of later quality of life. The importance of health-care resource allocation and psychosocial and behavioural intervention to the outcome after moderate traumatic brain injury is discussed.     

中重度颅脑损伤后血清三碘甲腺原氨酸水平变化与预后的关系

目的研究中重度颅脑损伤后血清三碘甲腺原氨酸水平变化与预后的关系。方法应用酶联免疫定量分析法多次检测164例中重度颅脑损伤患者游离三碘甲腺原氨酸(FT_3)、三碘甲腺原氨酸(T_3)水平的动态变化,同时记录GCS评分,观察分析血清FT_3及T_3水平变化与GCS变化的关系。结果不同程度的中重度颅脑损伤患者,其中恢复较好的患者在第7天和第14天检测的血清T_3和FT_3水平显著高于恢复较差的患者血清T_3和FT_3水平。结论中重度颅脑损伤T_3和FT_3的变化与预后密切相关,提高T_3和FT_3水平有望成为治疗中重度颅脑损伤的重要切入点。     

Serum S-100B protein and neuron-specific enolase after traumatic brain injury

OBJECTIVE: The aim of this study was to investigate S-100B protein and NSE as a serum marker of brain cell damage after traumatic brain injury. MATERIAL AND METHODS: Forty-one patients with traumatic brain injury were included in this prospective study. Venous blood samples for S-100B protein and NSE were taken after admission and on the next day. Serum levels of S-100 protein and NSE were compared with Glasgow Coma Scale score, computed tomographic findings and outcome after 3 months. RESULTS: Serum S-100B protein and NSE were significantly correlated with Glasgow Coma Scale score and outcome after 3 months. The significant correlation was found between the initial S-100B and NSE (P < 0.001). In patients without parenchymal injuries on computed tomographic scan such as epidural hematoma and concussion, the elevation of S-100B protein and NSE was observed. The initial values of S-100B and NSE in acute subdural hematomas with unfavorable outcome were significantly higher than in those with favorable outcome. Secondary increase of serum markers was associated with the presence of secondary insult such as hypoxia or hypotension, and was found to have an unfavorable outcome. CONCLUSIONS: Serum concentration and kinetics of S-100B protein and NSE provide the clinical assessment of the primary brain damage and have a predictive value for outcome after traumatic brain injury.     

Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients

BACKGROUND: Adult brain injury studies recommend maintaining cerebral perfusion pressure (CPP) above 70 mm Hg. We evaluated CPP and outcome in brain-injured children. METHODS: We retrospectively reviewed the hospital courses of children at two Level I trauma centers who required insertion of intracranial pressure (ICP) monitors for management of traumatic brain injury. ICP, CPP, and mean arterial pressure were evaluated hourly, and means were calculated for the first 48 hours after injury. RESULTS: Of 188 brain-injured children, 118 had ICP monitors placed within 24 hours of injury. They suffered severe brain injury, with average admitting Glasgow Coma Scale scores of 6 +/- 3. Overall mortality rate was 28%. No patient with mean CPP less than 40 mm Hg survived. Among patients with mean CPP in deciles of 40 to 49, 50 to 59, 60 to 69, or 70 mm Hg, no significant difference in Glasgow Outcome Scale distribution existed. CONCLUSION: Low mean CPP was lethal. In children with survivable brain injury (mean CPP > 40 mm Hg), CPP did not stratify patients for risk of adverse outcome.     

Use of injury severity variables in determining disability and community integration after traumatic brain injury

BACKGROUND: Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes. METHODS: Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data. RESULTS: Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed. CONCLUSION: Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI.     

Relative effects of brain and non-brain injuries on neuropsychological and psychosocial outcome

Based on the 242 consecutive surviving head injury cases and 132 general trauma cases, this study examined the contribution of brain and non-brain injuries to cognitive and psychosocial outcome 1 month postinjury. The study also examined the relationships among various head injury severity indices. The head injury severity indices were all correlated but patients with Glasgow Coma Scale scores in the mild range had broadly ranging scores on the other head injury severity indices (Abbreviated Injury Scale and time to follow commands). Neuropsychological outcome was related to brain injury severity, but was not independently influenced by severity of other systems injuries. Psychosocial outcome related to both brain and non-brain injuries independently. When evaluating trauma outcome, it is important to consider the contributions of both brain and other system injuries.     

Progressive brain injury

The aim of this study was to evaluate the clinical manifestations and prognostic factors of progressive brain injury following trauma. We reviewed the records of 779 patients with head injury who had an admission Glasgow Coma Scale of 9 or more; 70 (7.0%) developed progressive brain injury as evidenced on serial CT scans. Of these 70 patients, 19 (27.1%) had a subdural hematoma, 19 (27.1%) an epidural hematoma, 16 (22.9%) a cerebral contusion, 13 (18.6%) an intracerebral hematoma, and 3 (4.3%) a diffuse brain swelling. Three months after injury, 36 (51.4%) patients died, 2 (2.9%) were left in a vegetative state and 23 (32.9%) had a favorable outcome. The appearance of progressive brain injury was associated with patient age, admission Glasgow Coma Scale, injury mechanisms, skull fracture and hemorrhagic lesions on the initial CT scan. Patients with the extracerebral lesions deteriorated 4 hours after injury, whereas those with intracerebral lesions deteriorated 8 hours after injury. The outcome based on Glasgow Outcome Scale was significantly associated with age, type of intracranial lesion, Glasgow Coma Scale following deterioration, the mechanism of injury and surgical treatment. It is concluded that early repeated CT scan is indicated in patients with risk factors of developing progressive brain injury.     

颅脑损伤患者Rotterdam评分与术后挫伤性脑出血扩大的相关研究

目的探讨重型颅脑损伤患者Rotterdam头颅CT评分与去骨瓣减压术后挫伤性脑出血扩大的关系,明确挫伤性脑出血增加量与预后的关系。方法 212例行单侧去骨瓣减压术的颅脑损伤患者进入研究,记录年龄,GCS评分,瞳孔,实验室检查和最初的、术前最近的、术后首次的头颅CT数据。预后指标:外伤后6个月GOS评分。结果最初头颅CT的Rotterdam评分与去骨瓣减压术后的挫伤性脑出血是否扩大及血肿增加量相关。Rotterdam评分与死亡率和预后相关。去骨瓣减压术后挫伤性脑出血增加量与死亡率和预后相关。结论重型颅脑损伤患者最初的Rotterdam头颅CT评分可以预测去骨瓣减压术后脑挫伤出血扩大的风险,且与预后相关。     

Head computed tomography scans in trauma patients with seizure disorder: justifying routine use

HYPOTHESES: A majority of trauma patients with known seizure disorder with seizure activity were noncompliant with their medications, normal neurologic examination findings would predict negative results of head computed tomography (CT) scans, and the yield of CT scans would be insufficient to justify their routine use. DESIGN: Retrospective consecutive case series. MAIN OUTCOME MEASURES: Blood levels of antiepileptic drugs, predictive values and receiver operating characteristic curves of Glasgow Coma Scale scores, and findings on head CT. SETTING: Urban trauma center. PATIENTS: All trauma patients treated between September 1995 and June 2002 with seizure-related illness. RESULTS: The diagnosis of seizure identified 356 patients. Most (62%) had preexisting seizure disorder. Of the 101 who had antiepileptic drug levels drawn, 75% of these patients were noncompliant. The negative predictive value of a Glasgow Coma Scale score of 15 for intracranial abnormalities on CT scans was 90%. Receiver operating characteristic curve analyses of Glasgow Coma Scale score vs head CT abnormalities for all patients with seizure activity showed the area under the curve was 0.53, indicating poor discriminating ability. Intracranial abnormality was identified in 27% if the seizure resulted from injury and in 11% if the seizure preceded injury (P = .001). CONCLUSIONS: Neurologic examination is an unreliable predictor of intracranial injury in patients with seizure disorder. In trauma patients with seizure activity, the yield of CT scans in finding unsuspected intracranial abnormalities justifies its routine use regardless of prior history.     

Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury.

BACKGROUND: Decompressive craniectomy has historically served as a salvage procedure to control intracranial pressure after severe traumatic brain injury. We assessed the safety and feasibility of performing craniectomy as the initial surgical intervention. METHODS: Of 29 consecutive patients undergoing emergent decompression for severe traumatic brain injury with horizontal midline shift greater than explained by a removable hematoma, 17 had traditional craniotomy with or without brain resection and 12 underwent craniectomy. RESULTS: The craniectomy group had lower Glasgow Coma Scale scores at surgery (median, 4 vs. 7; p = 0.04) and more severe radiographic injuries (using specific measures). Mortality, Glasgow Outcome Scale scores, Functional Independence Measures, and length of stay in both the acute care setting and the rehabilitation phase were similar between the surgical groups. CONCLUSION: Despite more severe injury severity, patients undergoing initial craniectomy had outcomes similar to those undergoing traditional surgery. A randomized evaluation of the effect of early craniectomy on outcome is warranted.     

Prediction of outcome at discharge from acute care following traumatic brain injury

OBJECTIVE: To compute outcome probabilities for persons with traumatic brain injury at discharge from acute care. PARTICIPANTS: Three hundred thirty-nine patients with traumatic brain injury (239 mild, 48 moderate, 52 severe). SETTING: Level I trauma center. MAIN MEASURES: Predictor variables considered were age, education, Glasgow Coma Scale score, duration of posttraumatic amnesia, cerebral imaging results, and need for neurosurgical intervention. Outcome measures were Extended Glasgow Outcome Scale and discharge destination. RESULTS: Logistic regressions showed that a shorter posttraumatic amnesia decreased the probability of moderate to severe disability. Moreover, discharge home was less probable for patients with positive cerebral imaging. CONCLUSION: This model can help predict rehabilitation needs upon discharge from an acute care hospital.     

Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome

BACKGROUND: Geriatric trauma patients have a worse outcome than the young with comparable injuries. The contribution of traumatic brain injury (TBI) to this increased mortality is unknown and has been confounded by the presence of other injuries. The purpose of this study was to investigate the role of age in the mortality and early outcome from isolated TBI. METHODS: This was a retrospective analysis of all adult patients with isolated TBI (Abbreviated Injury Scale score > or = 3) admitted during a 5-year period to two Level I trauma centers. Mortality, Glasgow Outcome Scale score at discharge, therapy, and complications were compared for elderly (age > or = 65 years) and younger patients. RESULTS: Of 694 patients, 22% were defined as elderly. The mortality for the elderly group was twice that of their younger counterparts (30% vs. 14%, p < 0.001), even for those with mild to moderate TBI (Glasgow Coma Scale score of 9-15). Thirteen percent of elderly survivors had a poor functional outcome (Glasgow Outcome Scale score of 2 or 3) at hospital discharge versus 5% in the young group (p < 0.01). Independent factors associated with a high mortality were age and Glasgow Coma Scale score. CONCLUSION: The mortality from TBI is higher in the geriatric population at all levels of head injury. In addition, functional outcome at hospital discharge is worse. Although some of this increased mortality may be explained by complications or type of head injury, age itself is an independent predictor for mortality in TBI.     

孕酮治疗急性重型颅脑损伤疗效和作用机制的临床研究

目的 探讨孕酮治疗急性重型颅脑损伤病人的作用机制和疗效。方法56例急性重型颅脑损伤病人随机分成常规治疗组（／1=30）和孕酮治疗组（／1=26）,比较两组患者急性治疗期格拉斯哥昏迷评分（GCS）和格拉斯哥预后评分（GOS）、神经功能恢复和生活质量状况（KPS）。患者入院当时、第5天和第10天,分别抽取静脉血,采用放射免疫分析法测定血清孕酮和TNF-α ,酶标放射免疫法测定15-F2t-isoprostane（15-F2t-IPs）。结果 两组患者死亡率、急性治疗期GCS评分、治疗第10天COS评分和语言及运动障碍程度分级评估,均无显著差异（P〉0．05）;治疗后3个月随访,孕酮治疗组患者COS评分、语言障碍程度分级评估和远期生活质量评估,均明显优于常规治疗组（P〈0．05）;两组患者运动功能障碍程度分级评估无显著差异（P〉0．05）。入院第5天,常规治疗组患者血清15-F2t-IPs和TNF-α 均有增高,第10天下降。与常规治疗组比较,孕酮治疗组患者入院第5、10天血清孕酮显著增高（P〈0．05）;血清TNF-α 和15-F2t-IPs显著减低（P〈0．05）。结论应用孕酮治疗急性重型颅脑损伤,可以促进病人神经功能康复,改善预后;孕酮对急性重型颅脑损伤病人的神经保护作用与其抑制脑损伤后脂质过氧化反应和炎症反应有关。     

Cerebral endothelial injury in elderly patients with severe head injury measured by serum thrombomodulin and von Willebrand factor

Elevated serum levels of thrombomodulin (TM) and von Willebrand factor (vWf) are good indicators of injury and activation of cerebral endothelium in patients with severe simple head injury. The present study evaluated cerebral endothelial injury or activation as the serum levels of TM and vWf in elderly and younger patients with similar brain trauma, to evaluate the primary parenchymal injury of the brain. Patients with head injury were classified into the young group (16-30 years), the middle-aged group (31-65 years), and the elderly group (over 66 years). There was no difference in Glasgow Coma Scale on admission between the three groups. The serum levels of TM and vWf at 2 hours after injury were significantly higher in the elderly group than in the other groups. However, the serum levels of TM and vWf were not significantly different at 3 and 7 days after injury. Cerebral endothelial activation and injury were significantly higher in elderly patients just after head injury than in younger patients, which suggests that greater sensitivity to endothelial injury and activation may be important in the worse outcome after head injury in elderly patients compared with younger patients.     

One-year follow-up of patients with mild traumatic brain injury: occurrence of post-traumatic stress-related symptoms at follow-up and serum levels of cortisol, S-100B and neuron-specific enolase in acute phase

OBJECTIVE: To investigate serum levels of cortisol (a biochemical marker of stress), S-100B and neuron-specific enolase (two biochemical markers of brain tissue injury), in acute phase in mild traumatic brain injury patients and the occurrence of post-traumatic stress-related symptoms 1 year after the trauma. METHODS: Blood samples were taken in patients (n = 88) on admission and approximately 7 hours later for analysis. Occurrence of post-traumatic stress-related symptoms was assessed for 69 patients using items from the Impact of Event Scale questionnaire (IES) at follow-up at 15 +/- 4 months after the injury. RESULTS: Serum levels of cortisol were more increased in the first sample (cortisol/1, 628.9 +/- 308.9 nmol L-1) than in the second blood sample (cortisol/2, 398.2 +/- 219.4 nmol L-1). The difference between these samples was statistically significant (p < 0.001). Altogether 12 patients (17%) showed post-traumatic stress related symptoms at the time of the follow-up. Stepwise forward logistic regression analysis of symptoms and serum concentrations of markers revealed that only S-100B in the second sample was statistically significantly (p < 0.05) associated to symptoms (three symptoms of the avoidance sub-set of IES). CONCLUSION: A major increase in serum concentrations of cortisol indicates that high stress levels were reached by the patients, in particular shortly ( approximately 3 hours) after the trauma. The association between the occurrence of post-traumatic stress related symptoms and serum levels of S-100B (generally considered as a biochemical marker of brain injury) seem to reflect the complexity of interactions between brain tissue injury and the ensemble of stress reactions.